Exam 1

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Exam 1
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2013-05-20 01:25:38
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Nursing Health Assessment
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Exam 1
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  1. Nursing Process
    AD PIE

    Assessment, diagnosis, planning, intervention, evaluation
  2. Assessment
    process of collecting, validating, and clustering data.

    evaluation of patients condition based on data collected from labs, medical history and patients account of symptoms.

    •Determines the client’s: –baseline–normal function–presence of (or risk for) dysfunction–strengths
  3. Nursing Diagnosis
    Goal is to diagnose & treat human response to actual or potential health problems

    collected data-> diagnosis

    »Pneumonia vs. Ineffective airway clearance     r/t inflammation and presence of secretions
  4. Planning
    set goals and outcomes
  5. Implementation
    carry out plan
  6. Evaluation
    determine effectiveness of plan
  7. actual nursing diagnosis
    identify an occurring health problem
  8. potential nursing diagnosis
    identify high risk health problems that will occur unless take preventative measures.
  9. possible nursing diagnosis
    needs further data to support it
  10. Assessment: problem focused
    previously diagnosed. Why they are in the hospital. Focus on one system but consider other systems
  11. Assessment: Emergency
    • evaluate heart lung brain, very rapid
    • ABC
  12. Assessment: Time-lapsed
    screening patters. Recheck
  13. Assessment:Admission
    large amount of info, use more tools. Example long term care. (heat to toe to emergency)
  14. Subjective Data:
    Symptoms. Health history, how patient feels, sensations, beliefs, perceptions
  15. Objective Data:
    • Signs.
    • Measurable.
    • physical examination, diagnostic studies.
  16. Primary Data Source
    Patient
  17. Secondary Data Source:
    everyone but the patient (family, friends, old medical records, pcp)
  18. Primary Preventative Care
    focuses on health promotion and guards against health problems. minimize risk of health problems. PREVENTION

    Health fairs, immunizations, nutritional instruction
  19. Secondary Preventative Care
    early detection, prompt intervention, health maintenance for patients with health problems.

    monitor condition
  20. Tertiary Preventative Care:
    rehabilitative or extended care.

    skilled nursing facilities, long term care, home care, hospice.
  21. ADL vs IADL
    • Activities of daily living
    • instrumental activities of daily living (use phone, shopping, travel)
    •     AREACTIVITIES NECESSARY TO BE INDEPENDENT IN SOCIETY S
  22. observation: general Survey
    • first impression, overall status
    • grooming, gait, appearance of health, affect, level of consciousness, mental health status, posture, mobility, distress
  23. Interview Phase
    • preparatory
    • introductory: introduction, explain purpose, time frame 
    • [acknowledge, introduce, duration, explanation and thank you]
    • working: data collection
    • termination: summarize and state findings, discuss follow up
  24. Physical examination
    • inspection
    • palpation
    • percussion
    • auscultation
  25. Validate Data
    • subjective and objective should support each other. confirm, clarify, verify.
    • sources: patient, family, health care providers, health records, diagnostic tests.
  26. Maslow’s Hierarchy  of Needs
  27. Nursing Diagnosis 3 part system
    PES

    • Problem  (NANDA)
    • Etiology (related to)
    • symptoms (as evidence by)
  28. PQRST
    • Precipitating/palliative: what doing when problem started, anything make it better/worse
    • Quality/Quantity: describe symptom, feel like, sound like, how often
    • Radiating/Region: point where, does it spread? other symptoms
    • Severity: 0-10
    • Timing: when did it start, how often, for how long?
  29. Genogram
    identify familial risks factors at a glance.
  30. Integumentary System Normal findings
    • žSkin normal color and turgorž
    • Warm and dryž
    • No open wounds or lesions
    • žHair and scalp without lesion or infestations.ž
    • Nail beds pink and smooth
    • žNail base angle 160 degrees
    • žNail folds without redness or indurationž
    • Capillary refill < 3 seconds
  31. Nose sinuses


    1. Frontal•2. Ethmoid•3. Maxillary•Sphenoid lies behind the Ethmoid

    children: frontal develop at 7 yrs, maxillary and ethomoid at birth
  32. Inspection
    • look
    • general survey
    • Direct: directly look at patient
    • Indirect: use equipment
  33. Palpation
    • touch
    • light: 1/2 inch
    • deep: + 1/2 inch
  34. Percussion
    • tapping.
    • assess for masses, organs, pulsations, rigidity etc.
  35. Auscultation
    • hearing direct or indirect
    • use validation (someone else check )
  36. vital signs
    •  temperature, pulse, bp
    • why? establish baseline, monitor, evaluate response, identify problems
  37. Pulse
    • Normal 60-100
    • force of contraction
    • stroke volume: amount of blood ejected
    • CO=SV X HR
    • tachycardia
    • bradycardia
  38. Tachycardia
    more than 100 bpm
  39. Bradycardia
    less than 60 bpm
  40. Respirations-normal?
    normal 12-20 bpm
  41. Eupnea
    • normal respirations
    • 12-20
  42. tachypnea
    more than 20 bpm
  43. bradypnea
    less than 12 bpm
  44. apnea
    absence breathing for more than 15 seconds
  45. Dyspnea
    difficulty breathing
  46. Tidal Volume
    • depths of respiration
    • 300-500 ml is normal
  47. Blood Pressure
    • 100-120 systolic
    • 60-80 diastolic

    BP= CO X PVR
  48. Referred Pain
    felt at site other than the site of origin
  49. Radiating Pain
    pain extends.
  50. Clubbing
    • nail base angel greater than 180 degrees
    • respiratory, circulatory, cirrhosis, thyroid
  51. Turgor
    • gently pinch skin cause tenting
    • decreased turgor means dehydration
  52. Capillary refill
    on nial, less than 3 seconds is normal
  53. Primary Lesion
    initial alteration of skin (macule, papule, nodule)
  54. Secondary Lesion
    arises from change in primary lesion caused by external forces such as trauma, scratching, infection etc.
  55. Ulcers stages
    • 1: nonblacheable erythema of intact skin
    • 2: partial thickiness loss in both epidermis and dermis
    • 3: full thickess loss involving subcutaneous tissue
    • 4: full thickness loss involving muscle, bone, or supporting structure
    • 5: covered with eschar, cannot be staged without debridement
  56. Melanoma Assessment
    • Asymmetry
    • Border is irregular
    • Color varies
    • Diameter is more than 5 mm
  57. Fontanels/suture closures
    • Anterior- 10-18 months
    • Posterior- 2 monts
  58. Bruits
    • rushing blood sound due to obstruction
    • outside heart
  59. # teeth compare adults and childre
    • adult: 32
    • child: 20
  60. Integumentary Pregnant considerations
    • cholasma: brown pigmentation on face
    • gums: hypertrophy
    • thryroid may be palpated due to increased hormone levels.
  61. Cholasma
    brown pigmentation during pregnancy
  62. Inspection of outer ear
    • helix
    • maxillary
    • tragus

    otoscope adult 1/2 inch, child 1/4 inch
  63. Whisper Test
    • low pitch, low tone
    • stand 1-2 ft behind patient and whisper 3-4 unrelated words
  64. Rinne test
    vibrating tuning form on mastoid process (behind ear) and in front of ear

    • AC:BC
    • 2:1
  65. Vertigo
    dizzy due to inner ear inbalance
  66. Presbrycusis
    Hearing loss with aging of high pitched sounds
  67. Otorrhea
    drainage
  68. Choesteatoma
    abnormal skin growth in middle ear behind eardrum
  69. Tinnutis
    • ringing
    • usually with asprin toxicity
  70. Otalgia
    earache
  71. Snells test
    test for visual acuity for distance
  72. Rosenbaum Test
    • for nearsightedness
    • 14 inches away, move further is a fail.
  73. PERRLA
    • pupils eaqual, round, reactive to light
    • accommodation
  74. Visual Accommodation
    process by which the vertebrate eye changes optical power to maintain a clear image (focus) on an object as its distance varies
  75. Cardinal Signs of Gaze
    one of six positions to which the normal eye may be turned. This test evaluates the functioning of the six extraocular muscles and cranial nerves III, IV, and VI
  76. Direct and consensual pupil response
    constriction of illuminated pupil and consensual opposite pupil restricts
  77. Corneal Light Reflex
    light reflection test (extraocular membrane)

    symmetry of light reflection is normal
  78. Myopia
    near sightedness
  79. hyperopia
    farsightedness
  80. Ptosis
    falling of eyelid
  81. Red Reflex
    normal finding, otherwise suggest cataracts retinal detachment
  82. Optic Disc
    located nasally
  83. macula
    located on opposite side of optic disc
  84. astigmatism
    irregular curvature of lens
  85. Lacrimal Gland
    above eyelid to naso lacrimal duct (corner- inner canthus)
  86. Cornea Reflex
    normal blink, eyes tear
  87. Amblyopia
    lazy eye test. with corneal light reflex, binocular vision, cover un cover
  88. Strabismus
    alignment of eye
  89. Nasal patency
    cover one nostril at a time
  90. Bells Palsy
    weakness/paralysis of one side of face, usually goes away
  91. Tonsil grades
    • 1: WNL
    • 2: enlarge but separate from uvula
    • 3: tonsils touch uvula
    • 4: tonsils touch eachother
  92. Buccal Mucosa
    • Inside lining of mouth
    • good for assessing skin color on darker skin ppl
  93. Stensen's ducts
    • upper, drain saliva from parotid gland
    • normal: pink and no lesions
  94. Wharton's ducts
    lower, under tongue, drain saliva from submandibular galnds
  95. Frenulum
    under tongue
  96. Uvula
    • midline
    • prevents food from entering nasal passages
  97. geographical tonue
    • normal finding
    • raised papillae
  98. Hairy Tongue
    black papilae
  99. Lichen Planus
    bilateral on buccal mucosa white lace-like erruptions
  100. Leukoplakia
    White plaque on buccal mucosa and gingivae or tongue (HIV)
  101. Inspection of neck
    • skin
    • carotid and jugular
    • trachea
    • thyroid (ask to swallow, should rise)
    • carotid (for bruits with bell)
  102. Torticollis
    abnormal, asymmetrical health/neck positions
  103. Laterocollis
    tipped toward shoulder
  104. rotational Torticollis
    rotates along logitudal axis
  105. Anterocollis
    forward flexion
  106. retrocollis
    hyperextension of head/neck backwards
  107. Visceral Pleura
    lines lungs
  108. Parietal Pleura
    line chest and diaphragm
  109. Lungs lobes on each side
    • right-3
    • left-2
  110. pallor
    paleness, due to low hemoglobin
  111. Cyanosis
    blue color of skin due to low oxygen
  112. Hypoxia
    low levels of oxygen, causes cyanosis
  113. Anteroposterior daimeter
    • normal 1:2, barrel shape is 1:1
    • infants are 2:1
  114. Crepitus
    upon palpation, subcutaneous air (check around wound sites)
  115. Excrusion
    • chest expandability (butterfly)
    • diaphragm is 3-5 cm
  116. Tactile fremitus
    • "99"-vibrations
    • resonance is normal
    • increased: fluid in lungs
    • decreased: air trappings (asthma etc. )
  117. Auscultation: bronchial
    • (over trachea and larynx)
    • loud, hight pitched and hollow I<E
  118. Auscultation: Bronchivesicular
    • (over major bronchi/ manybrium) moderate, medium pitched
    • I=E
  119. Auscultation: vesicular
    •  (over periphery lung fields) soft, low pitched
    • I>E
  120. Percussion: lungs
    • over intercostal spaces
    • dullness: fluid, tumor, pulmonary edema
    • hyperessonance: air
    • normal: dullness over bones and organ, otherwise resonance.
  121. Wheeze
    • high pitched musical sound 
    • continuous
    • narrowing of airway
  122. epiglottis
    prevents food from entering trachea
  123. Crackles/rales
    • Popping sound
    • discontinous
  124. Rhonchi
    • rattle during expiration in upper large airway resulting from secretions
    • low pitched, continuous
  125. Stridor
    • harsh, high pitched during inspiration
    • upper airway (trachea or larynx)
  126. Friction Rub
    high pitched, squeaking sound in pleural layers both inspiration and expiration
  127. Bronchophony
    abnormal voice sounds, clearer transmission of spoken voice. say 1, 2, 3
  128. Egophony
    abnormal voice sounds ee to aaa
  129. Pectorilogy
    • whisper 1,2,3
    • normal: hear indistinct sound
    • abnormal: hear clearly
  130. respiratory developmental considerations
    • infants: nose breathers, belly breathers, respirations are faster
    • elderly: increase AP- barrel shape
  131. Electrical System of cardio
    • SA  node
    • AV node
    • bundle of his
    • branches right and left
    • purkinje fibers
  132. Cardiac Output
    blood ejected per minute
  133. Murmur
    turbulent sound through chambers/valves hearing in heart
  134. Palpation Cardiac
    • Apex (mitral)
    • LLSB (tricuspid area)
    • Base left (pulmonic area)
    • Base right (aortic area)
    • epigastric
  135. Auscultation Cardiac
    APE T M

    First with diaphragm then bell back up

    Apical (mitral) for one minute, rythm
  136. Vital signs include
    •Temp, Pulse, Resp, BP, SaO2, and Pain
  137. Surface vs core temperature
    • •Surface: oral, axillary, skin, and tympanic
    • •Core:  rectal, bladder, and hemodynamic probe
  138. Oximetry
    • 95-100% normal
    • •SaO2 reflects the percentage of hemoglobin molecules carrying oxygen
  139. temperature normal
    100.4-96.8
  140. Cranial Nerves
    • I - Olfactory nerve
    • II - Optic nerve
    • III - Oculomotor nerve
    • IV - Trochlear nerve
    • V - Trigeminal nerve/dentist nerve
    • VI - Abducens nerve
    • VII - Facial nerve
    • VIII - Vestibulocochlear nerve/Auditory nerve
    • IX - Glossopharyngeal nerve
    • X - Vagus nerve
    • XI - Accessory nerve/Spinal accessory nerve
    • XII - Hypoglossal nerve

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